The President’s COVID-19 Infection
Most of the news of the last week has surrounded President Trump’s diagnosis and apparent rapid recovery from COVID-19. As of right now, we do not know where the infection occurred. The Leading candidate locations include events surrounding the nomination of Judge Barrett to the Supreme Court and the preparation for the first Presidential Debate. There is some degree of overlap between these two major events, but there were some people who were at one, but not the other. Regardless, there are a couple of key points that can be taken.
First, testing cannot “clear” someone from the risk of being infected. Testing requires a high enough level of virus in the sample for there to be a positive result. Generally, it takes two to three days from infection to reach that point. The fact that someone has a negative screening test does not mean that they will not reach that point in the next day or even just several hours later. Yes, testing can reduce the chance that someone is infectious in a short window after testing, but that window is often shorter than the turnaround time for the results. That is, except in the case of someone who is asymptomatic, which may be as high as 15% of all people who are infectious. In those cases, testing is the only way that an infectious person will be discovered. Considering all of that, testing is only valuable as part of a larger prevention strategy. In situations where it is critical to reducing the risk of infection, other mitigation measures must be employed in addition to testing.
This can include:
- Quarantine for up to 14 days prior to being in a critical zone.
- Always wearing masks when near others.
- Ensuring good ventilation.
- Practicing social distancing.
As WorldClinic has demonstrated with bubbles we have successfully managed, the only time it is even conceivable to let down your mitigation guard is if the people in the bubble go through a test and quarantine regimen. Then, they are in a tightly controlled environment where no one, including support staff, go in and out without significant mitigation measures. Even then, with a critical location, some degree of mitigation is still advisable.
The next point from the President’s experience is that there are now multiple routes of treatment for the disease. Some potential avenues of treatment have been mentioned in previous discussions, but we will review the President’s regimen to explain each of them:
- Antiviral medications are those that directly attack the biochemical properties of the virus and either disrupt its structure or make the virus incapable of replicating. The President got the medication Remdesivir, from Gilead Pharmaceuticals. Gilead has announced that Remdesivir is available in adequate quantities to meet all expected demand for the foreseeable future and is available to hospitals through typical pharmacy supply chains. Remdesivir is not indicated for patients with mild symptoms, but it is also no longer limited to patients who are at or near intensive care criteria.
- Next are the immunologic therapies. There are two basic types of these. The older is hyperimmune serum. This is where blood is taken from patients who have had the disease and the portion of the blood containing antibodies is concentrated and administered to patients. The second is where the specific antibodies against the target, in this case, a specific protein on the SARS-CoV2 virus, is isolated and then coaxed into reproducing in the lab. This concept is used in several areas of medicine routinely, but the most promising and well-known use for COVID-19 is from Regeneron. This what the President received, although this is generally not available outside of study programs because it has not yet received Emergency Use Authorization, although the application is pending. Another major pharmaceutical maker, Eli Lilly, has a similar product also moving to Emergency Use Authorization very soon. The data on both are excellent.
- The third is a steroid anti-inflammatory. This is being used as soon as there is evidence of potential lung inflammation. Contrary to what has been commonly stated in the news, this is no longer held in reserve for the most ill patients but instead used whenever there is evidence of vascular inflammation, especially in the lungs. In the President’s case, he did have two episodes where his blood oxygen levels dropped. These levels did not drop to a dangerous point, but enough to suggest to the medical team that the steroid, betamethasone, may be useful.
- Two other very safe additions were made to his therapy. The exact mechanism for these fighting COVID-19 is not as well understood, but he was given the standard supplements Zinc and D3. Zinc is thought to inhibit the virus’s ability to hijack a cells’ biochemistry to make more copies of the virus and Vitamin D3 is less well understood but has been clearly associated with better outcomes.
As far as the President’s course goes from here, remember that the CDC recommendation is NOT to continue testing him for the presence of the virus. In up to 20% of patients, they may continue to shed non-infectious viral particles that will test as positive on PCR testing. This does not mean that there is an ongoing infection or that the patient is in any way infectious. Instead of testing, the recommendation is to wait 10 days and if symptoms have decreased and fever is absent for at least 24 hours, there is no reason to continue isolation. Some patients continue to experience some symptoms beyond that 10-day period, but that does not mean they are infectious. We can expect much debate over this, but many would argue that the President is now significantly more likely to have some relative immunity to COVID-19. The CDC recommendations do not go that far, however.
Planning for Holiday Travel
In most of the world, the late fall and early winter are traditionally significant travel seasons and much more compact than the summer vacation season. Typically, this means packed airports, planes, trains, and roads. While travel will likely be much decreased this year, unfortunately, the travel capacity has also been cut, so there is still a risk of high density on the actual planes and trains. I have talked about planes before and can reassure you that not only is the ventilation on planes well designed for combatting an infection like SARS-CoV2, there is also an absence of significant evidence of transmission on planes. Note, that this absence of evidence only holds true when personal mitigation measures, especially including masks, are applied.
If you are considering travel plans, remember that not all places have an equal risk of transmission, and that risk of transmission changes with time and importantly with what you do at your destination. Mixing households from different places, and then separating them back to their original locations is a very powerful way to spread disease. Ideally, if your location has a significantly different risk level than where you are traveling, you may want to consider forgoing travel for just a few months until vaccines are getting out to the public.
The key numbers to remember, are 1, 10, and 25. These represent cases per 100,000 of the population per day and are ideally averaged over a 7-day period. Areas that are on the order of 1 or low single digits are fairly safe. Higher single digits up to 10 are still relatively safe, but mitigation measures become more important. 10 to 25 represents fairly well-spread community transmission, meaning that the virus is out there and you can catch it without knowing where your exposure was, so mitigation is critical, and greater than 25 is an area where you should not travel to.
For the United States, the Washington Post has an excellent COVID page, updated daily, that provides this data down to the county level (note that at the county level, it publishes counts for the last week, so the published number has to be divided by 7). In Europe, the European CDC publishes a similar graphic with data to the provincial level. (they use color coding and different thresholds, but the 4-level principle is similar).
In both the US and Europe, the concern is rising about a second wave, and some larger level mitigation approaches are being reinstituted in several places. Take this information as a reminder that COVID-19 is not over and continued reasonable mitigation, including careful consideration of any travel until a vaccine is out, will all work together to get us through these next few months.
